Cognitive Misbehaviour?

Published The Times – November 4th 2006

Five main mental health charities have announced their support for an expansion ofNHS psychotherapy. But is Cognitive Behaviour Therapy the best investment?

An ideological struggle has broken out between two of our leading ‘happiness thinkers’ about whether the claims advanced in favour of Cognitive Behavioural Therapy (CBT) can be justified. On one hand, Tony Blair’s adviser the economist Professor Richard Layard is about to launch a health service programme of CBT nationwide employing 10,000 novice recruits. On the other, psychologist Oliver James tells readers of the
Daily Mail that CBT only appeals to Tony Blair because it is ‘quick, cheap and simplistic’ but is seriously lacking in long-term efficacy. What does the evidence say?

First, that it is reasonable for the Government to turn to the psychological therapies as the frontline treatment for conditions such as anxiety and depression when the routine
prescription of benzodiazepine tranquillisers and many anti-depressants costs too much (more than £11 billions pa) and yields disappointing results. Dr Allen Moses, Head of Genetics research for Glaxo-Smithkline, admitted as much in December 2003 by saying: “The vast majority of drugs – more than 90 per cent – only work in 30 or 50 per cent of the people”.

Certainly in CBT’s favour is the fact that as a talking therapy it does what it says on the label – attempts to train your cognitions then alters your behaviour. To take the simplest example, if you believe nobody loves you then the therapist only has to produce evidence that one person does love you for you to be proved wrong. Similarly, if your behaviour disobeys what we might call the laws of life (never eating properly, not exercising etc) why on earth would you expect your mind to be happy?

However, the fact that in a relatively short period CBT has produced an impressive research base must be qualified by the observation that because CBT is tasked with
‘symptom removal’ not ‘treatment of the whole person’ this research has proved relatively easy and cheap to undertake. Setting out to measure whether someone has got rid of a single symptom (such as a spider phobia) leads to only two relevant answers – yes or no. It is much more difficult to evaluate a therapy seeking to show whether you have gone from ‘greater’ to ‘less’ unhappiness but the experience in itself might prove more life-changing.

Critics also observe that the case for standard CBT has been significantly favoured by the way in which the guidelines on anxiety and depression sponsored by the National Institute for Health and Clinical Excellence (NICE) are presented. Much of the pro-CBT information is featured in the headline summaries; significant qualifying remarks about other equally valid therapies are found in the small print which it is sometimes feared a proportion of GPs may not read.

This matters because Oliver James is right about research in the longer term. According to the most authoritative sources, at least half those patients receiving CBT for panic disorder had suffered relapse or sought new help after 24 months. For depression, a clear (and fairly consistent) finding is that, after one year, only about a quarter of a sample treated with CBT will remain well. Last Monday, at a conference on Practice-Based Commissioning in Manchester, Professor Layard publicly admitted that CBT is really appropriate for only about 40% of patients overall.

Stunningly, the largest body of evidence into counselling outcomes, the 35,000 cases comprising the CORE Survey, has been totally ignored by NICE and Layard alike. Looking at the figures just for depression, CORE shows there is no significant difference in the long-term success rates for CBT over traditional forms of therapy such as ‘person-centred’ or ‘psycho-dynamic’: CBT works for 75% of patients; the rest for 76%.

So a summary of the evidence tends to show that ALL talking treatments are roughly equal in effectiveness because of course it is the relationship with the therapist that counts. Patient choice should count too. I suggest the NHS would be unwise to put all its eggs into a CBT basket.